[ESC guidelines 2021 on cardiac pacing and cardiac resynchronization therapy : What's new?]

Perioperative coagulation activation after permanent pacemaker placement

BACKGROUND

Bradyarrhythmias are typically treated with permanent pacemakers (PM). The elimination of bradyarrhythmia by PM implantation improves the patient's quality of life and prognosis, but it can also result in a number of sequalae. It is still unclear how PM implantation affects the hemostasis system's parameters and how such parameters relate to different consequences after PM placement.

AIM

To assess the blood coagulation factor activity in PM patients throughout the perioperative period.

METHODS

Patients treated in the Department of Surgical Therapy of Cardiac Arrhythmias and Pacing at the Ryazan State "Regional Clinical Cardiology Dispensary" from April 2020 to December 2021 were included in the study. Before surgery, 7 and 30 d after PM placement, peripheral venous blood samples were withdrawn to measure the level of blood coagulation factor I (FI) and the activity of blood coagulation factors II (FII), V (FV), VII (FVII), VIII (FVIII), IX (FIX), X (FX), XI (FXI), XII (FXII). We used an automatic coagulometer Sysmex CA 660 (Sysmex Europe, Germany) and reagents from Siemens (Siemens Healthcare Diagnostics Products GmbH, Germany).

RESULTS

The study included 146 patients. The activity of factors FV [147.7 (102.1-247.55)% vs 103.85 (60-161.6)% vs 81.8 (67.15-130.65)%, P = 0.002], FVIII [80.4 (60.15-106.25)% vs 70.3 (48.5-89.1)% vs 63.7 (41.6-88.25)%, P = 0.039], FIX [86.2 (70.75-102.95)% vs 75.4 (59.2-88.3)% vs 73.9 (56.45-93.05)%, P = 0.014], FX [188.9 (99.3-308.18)% vs 158.9 (83.3-230)% vs 127.2 (95.25-209.35)%, P = 0.022], FXI [82.6 (63.9-103.6)% vs 69.75 (53.8-97.6)% vs 67.3 (54.25-98.05)%, P = 0.002], FXII [87.6 (67.15-102.3)% vs 78.9 (63.4-97.05)% vs 81.2 (62.15-97.4)%, P < 0.001] decreased at 7 and 30 d after surgery; FII activity [157.9 (109.7-245.25)% vs 130 (86.8-192.5)% vs 144.8 (103.31-185.6)%, P = 0.021] decreased at 7 d and increased at 30 d postoperatively. There were no statistically significant changes in the FVII activity within 30 d after PM placement [182.2 (85.1-344.8)% vs 157.2 (99.1-259)% vs 108.9 (74.9-219.8)%, P = 0.128]. Subgroup analysis revealed similar changes only in patients on anticoagulant therapy. FXII activity decreased in patients on antiplatelet therapy [82 (65.8-101.9)% vs 79.9 (63.3-97.1)% vs 89.7 (75.7-102.5)%, P = 0.01] 7 d after surgery, returning to baseline values at 30 d postoperatively.

CONCLUSION

PM placement and anticoagulant therapy were associated with decreased activity of clotting factors FV, FVIII, FIX, FX, FXI, FXII in the postoperative period. FVII activity did not decrease within 30 d after PM placement, which may indicate endothelial injury caused by lead placement.

Comparison of His-Purkinje Conduction System Pacing with Atrial-Ventricular Node Ablation and Pharmacotherapy in HFpEF Patients with Recurrent Persistent Atrial Fibrillation (HPP-AF study)

BACKGROUND

There is currently no particularly effective strategy for patients with persistent atrial fibrillation accompanying heart failure with preserved ejection fraction (HFpEF), especially with recurrent atrial fibrillation after ablation. In this study, we will evaluate a new treatment strategy for patients with persistent atrial fibrillation who had at least two attempts (≧2 times) of radio-frequency catheter ablation but experienced recurrence, and physiologic conduction was reconstructed after atrioventricular node ablation or drug therapy, to control the patient's ventricular rate to maintain a regular heart rhythm, which is called His-Purkinje conduction system pacing (HPCSP) with atrioventricular node ablation.

METHODS AND RESULTS

This investigator-initiated, multicenter prospective randomized controlled trial aimed to recruit 296 randomized HFpEF patients with recurrent atrial fibrillation. All the enrolled patients were randomly assigned to the pacing group or the drug treatment group. The primary endpoint is differences in cardiovascular events and clinical composite endpoints (all-cause mortality) between patients in the HPCSP and drug-treated groups. Secondary endpoints included heart failure hospitalization, exercise capacity assessed by cardiopulmonary exercise tests, quality of life, echocardiogram parameters, 6-minute walk distance, NT-ProBNP, daily patient activity levels, and heart failure management report recorded by the CIED. It is planned to compete recruitment by the end of 2023 and report in 2025.

CONCLUSIONS

The study aims to determine whether His-Purkinje conduction system pacing with atrioventricular node ablation can better improve patients' symptoms and quality of life, postpone the progression of heart failure, and reduce the rate of rehospitalization and mortality of patients with heart failure.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR1900027723, URL: http://www.chictr.org.cn/edit.aspx?pid=46128&htm=4.

A Holistic View of Advanced Heart Failure

Advanced heart failure (HF) may occur at any level of left ventricular (LV) ejection fraction (LVEF). The latter, which is widely utilized for the evaluation of LV systolic performance and treatment guidance of HF patients, is heavily influenced by LV size and geometry. As the accurate evaluation of ventricular systolic function and size is crucial in patients with advanced HF, the LVEF should be supplemented or even replaced by more specific indices of LV function such as the systolic strain and cardiac power output and size such as the LV diastolic diameters and volumes. Conventional treatment (cause eradication, medications, devices) is often poorly tolerated and fails and advanced treatment (mechanical circulatory support [MCS], heart transplantation [HTx]) is required. The effectiveness of MCS is heavily dependent on heart size, whereas HTx which is effective in the vast majority of the cases is limited by the small donor pool. Expanding the MCS indications to include patients with small ventricles as well as the HTx donor pool are major challenges in the management of advanced HF.